WQ0000267_OIC Designation Form_20241018

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
Facility Name
NCAC 15A 8G .0201
TAB to Navigate Form
4k5 4!!Vure]t/ 1,V14/7-1;s
Facility Type/Classification: SI Facility Grade: N/A
Permittee Owner/Officer Name: (act/CS �a6/1
Permit # wQ dooaatl 7
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
JG' a /77 �"er
Email Address: $Sayer �%SCoun� nc. ot/
Permittee Signature: ,S.IS-T L .,--• Date:
ORC
Full Name: Sea Z? fR Work Phone: ( es-2
Email Address: -s 14, Ie ou 72 c, o ✓
Certificate Type: SI Certificate Grade: N/A Certificate #: `0/,?77a
Signature: Effective Date: l0�/7.?`
7—R—
"I certify that/ agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
7,
Full Name:AC 4 J Work Phone:
Certificate Type: SI Certificate Grade: N/A _ Certificate #:
Signature: Effective Date:
"I certify that I agree to my desig atio the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Backup ORC
Full Name: _ Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Email this form to: [e-mail]
AND
Send to your DEQ Regional Office (send to your contact or find emails here: www.deq.nc.gov/about/contact/regional-offices
or fax using this drop down list: Washington-943 Washington Sq. Mall, Washington, NC 27889 1 FAX: [phone] PH: 252-346-6481
Use the 2nd page only if you need to list additional Backups.
Revised 0212024